Opioid Prescribing in Dental Medicine

Joshua Rothschild, JD, MPH
September 13, 2021

There are about 1.7 million Americans per year who live withopioid use disorder. There are also about 1.6 million Americans per year who misuseprescription opioids for the first time and over 10 million Americans per year who misusethem overall. Of these people, nearly 50,000 Americans die each year from opioidoverdoses. These numbers are from before the COVID-19 pandemic, andunfortunately, most experts believe that opioid misuse has increased during thepandemic.  


Dental Medicine andthe Opioid Epidemic


Opioids are prescribed by dentists and physicians to treatpain that is not well-controlled by other medications. In the U.S., dentistsprescribe about 8.6% of prescription opioids. To put this inperspective, pain medicine physicians prescribe 8.9%, internalmedicine physicians 15.7%, and family physicians 20.5% of total opioidprescriptions. All medical specialties, including dentists, havebeen re-examining the use of opioids and reducing the number of prescriptionswhen possible. There has been a growing amount of research on opioids and painmanagement, and it turns out that in many cases, opioids are not more effectivethan other types of pain relief.


For instance, quality improvement research done by theUniversity of Michigan found that patients who were prescribed opioids did notreport less pain than patients who were given NSAIDs or acetaminophen for toothextraction. Patient satisfaction was also the same for patients who wereprescribed opioids and those given non-opioid medications. And both groups ofpatients called their dentists at the same rate after their extractions aboutpain, indicating that prescribing opioids had no positive effect in controllingpain versus other measures. This is just one of many studies thatshows that opioid prescriptions for dental pain are not as effective as oncethought.


Different Types ofDental Pain


Prescriptions to manage dental pain are typically giveneither because of a painful dental procedure (like an extraction) or trauma oralternatively for what’s commonly called “tooth pain” (but is more technicallycalled “odontogenic pain”). “Tooth pain” often results from an infectionthat causes inflammation, leading to the pain. In some cases, opioids are thebest way to manage either type of pain. But in most cases, non-opioid painmedications are just as effective but lack the side effects and potential formisuse. When American dentists prescribe opioids, the most common prescriptions are for hydrocodone andoxycodone.


How Do the U.S andU.K Compare?


The proportion of opioid prescriptions written by dentistsin the U.S. is 37 times higher than that of dentists in theU.K. This is despite the U.S. and the U.K. being extremely similar when it comesto oral health and dental treatment. In addition to thistremendously large difference in opioid prescribing practices between U.S. andU.K. dentists, the types of opioids prescribed are very different. While mostdental prescriptions for opioids in the U.S. are for hydrocodone and oxycodone,all dental prescriptions for opioids in the U.K. are fordihydrocodeine which has a lower potential for abuse.


What Happens with AllThose Opioids?


Despite U.S. dentists prescribing far more opioidsthan their U.K. counterparts, research has repeatedly shown that U.S. patientsdo not usually take their entire prescriptions. For example, recent research shows that only 46% of opioidpills prescribed after dental surgical tooth extractions are taken asprescribed, while the other 54% go unused three weeks after the extraction.This means that over 100 million opioid pills prescribed bydentists for tooth extractions go unused every year. In 2016, the Centers forDisease Control and Prevention (CDC) issued guidelines on opioid prescribing,recommending caps on dose size and days prescribed. In a study that analyzed over 1.4 million U.S.dental visits, it was found that 29% of opioid prescriptions from dentistsexceeded the dose sizes recommended by the CDC. In addition to dose sizes, theCDC also recommended that opioids prescribed at dental visits be for only a fewdays worth of the medication; it turns out that over half of these opioid prescriptionsexceeded this amount. We know from other research that 70% of misused prescriptionopioids originally came from a leftover prescription directly prescribed tothat user or their friends or family.


What Dentists areDoing About It


The dentistry profession sees the problem and has beenactively working to fix it. More and more dentists prescribe opioids only as alast resort and only after patients have tried other medications. In 2018, theAmerican Dental Association (ADA) issued a statement on opioid prescribing indentistry. The ADA statement supports mandatory continuingeducation for dentists on opioid prescribing best practices, a limitation ofseven days for prescriptions, and expansion of state prescription drugmonitoring systems. In addition, many dentists have begun encouraging patients to bring theirleftover opioid prescriptions back to their pharmacies to avoid thembeing lost or stolen. Most dentists now also communicate to patients that painis expected after many of these procedures; research has found that as long as patientsknow what to expect, they tend to handle the pain better.


TeleDentists Policyon Narcotics


The TeleDentistsfollow the rules and regulations for telehealth/teledentistry, and do notprescribe narcotics.